PATIENT CONSENT

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of removal of impacted ear wax is to provide accurate visualization of the ear canal and tympanic membrane (eardrum) to rule out an infectious process, improve hearing and provide relief of pain from impacted ear wax from the ear canal.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Injury to the ear canal during impacted wax removal.
• Injury/ perforation of tympanic membrane during impacted wax removal.
• Incomplete removal of impacted ear wax.
• Need for repeated ear wax removal.
• Patient discomfort during ear wax removal.
• Bleeding of ear following removal.

I understand that some patients do not respond successfully to impacted ear wax removal procedure. In some cases, the attempt to remove all of the impacted ear wax may not be completely successful. In these cases, the procedure may need to be repeated.

I understand that complications may result from a ear wax impaction removal. The most common complications include, but are not limited to: post-procedure infection, bleeding, swelling, and pain; injury to the ear canal or tympanic membrane; ear canal irritation.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in the process accurate visualization of ear canal and tympanic membrane (eardrum) to rule out infection, improve hearing and resolve discomfort from impacted ear wax. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of removal of a foreign body is to provide pain relief from foreign body presence and to decrease risk of infection.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Injury to the surrounding tissue during removal of foreign body.
• Incomplete removal of foreign body.
• Patient discomfort during and after procedure.
• Bleeding due to procedure.
• Infection due to procedure.

I understand that some patients do not respond successfully to foreign body removal procedure. In some cases, there is partial removal of the foreign body. In these cases, the procedure may need to be repeated.

I understand that complications may result from foreign body removal. The most common complications include, but are not limited to: post-procedure infection, bleeding, swelling, pain, and injury to surrounding tissue.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit in the process to provide pain relief from the foreign body presence and to decrease the risk of chronic infection or deformity if foreign body is left in place. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of receiving burn care with debridement, topical medication application and dressing is to provide improvement in overall healing, decrease scarring, provide pain management and to decrease the risk of infection.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Possible scarring despite adequate and optimal burn care.
• Injury to surrounding tissue with skin debridement of burn.
• Need for repeated skin debridement and burn management.
• Patient discomfort during burn treatment.
• Bleeding following burn treatment.
• Infection due to skin debridement.

I understand that some patients do not respond successfully to burn care. In some cases, the attempt to debride the burned skin, treatment with topical medications and application of dressings may not be completely successful. In these cases, the procedure may need to be repeated.

I understand that complications may result from burn treatment.. The most common complications include, but are not limited to: scarring despite treatment, post-procedure infection, bleeding, swelling, and pain.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide improvement in overall healing, decreased scarring and improvement in pain. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of wart destruction with cryotherapy is to decrease spread of warts, decrease overall growth of current wart(s) and encourage resolution of wart(s). Typically multiple cryotherapy sessions are required to achieve this goal.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Injury to surrounding tissues.
• Blistering following procedure.
• Need for repeated cryotherapy of warts for complete resolution of lesion(s) and reduce spread.
• Patient discomfort during treatment.
• Skin infection following procedure.
• Skin scarring.
• Bleeding if a callus is removed from the wart(s).

I understand that some patients do not respond successfully to wart destruction by cryotherapy. It is expected that the procedure will need to be repeated. Typically 3-4 treatments are required. Each treatment is usually 3 weeks apart.

I understand that complications may result from wart destruction by cryotherapy. The most common complications include, but are not limited to: post-procedure infection, bleeding, blistering, swelling, pain, injury to the surrounding tissue, scarring and allergy to medications or equipment used by your provider.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment will provide decrease spread of warts, decrease overall growth of current wart(s) and encourage resolution of warts. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of laceration repair is to provide minimized scarring, control bleeding and decrease risk of infection.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE:
Most common complications include but are not limited to:

• Injury to the surrounding tissue.
• Scarring despite closure of the laceration.
• Re-opening of laceration despite closure of the laceration.
• Need for surgical revision of a healed laceration.
• Patient discomfort.
• Bleeding.
• Infection.
• Allergic reaction to the medications and supplies used to close the laceration.

I understand that some patients do not respond successfully to closure of a laceration. In some cases, the attempts to close a laceration may not be completely successful. In these cases, the procedure may need to be repeated or revised at a later date.

I understand that complications may result from laceration closure. The most common complications include, but are not limited to: post-procedure infection, bleeding, swelling, and pain; injury to surrounding tissue, scarring, need for additional surgical revision or allergic reaction.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit of minimized scarring, control bleeding and decrease risk of infection. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. This procedure consent is written in lay-terms and should convey to you the risks and complications that could occur. Reviewing this document will outline what you can expect from the patient receiving elective circumcision. The end of this form allows you and the patient’s physician to attest that all questions have been answered to your satisfaction and that you are giving informed consent to proceed with treatment. You are advised to read this form carefully and use this opportunity as an information seeking session on incision and drainage of an abscess. If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks with incision and drainage of an abscess do not sign the form until all your questions have been answered.

Diagnosis
Abscess which is an advanced infection that has caused a localized collection of infected fluids (pus).
Name of Procedure
Incision and drainage of abscess to assist in healing and to allow treatment with antibiotics to work better.
Prognosis if the proposed treatment is not accepted
Infection will worsen.
Alternative Treatments
Observation with oral antibiotics.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• post procedure discomfort and swelling.
• bleeding.
• increasing infection at the site and recurring infection.
• scarring.
• complications of local anesthetic- allergic reaction.
• swelling.
• bruising.
• nausea / vomiting.
• localized pain and/or need for repeat of the procedure.
• Rare complications include injury to surrounding tissue. If complications occur, I am to contact my physician.

I understand that because of the patient’s known health condition(s), there maybe additional risks. I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to my physician to perform such procedures at her discretion if needed during the procedure. I understand that my insurance company may not cover this procedure. If this occurs, I understand that I am require to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

PARENT OR LEGAL GUARDIAN’S CONSENT
I, (parent or legal guardian) consent, with my signature, to local anesthesia being administered and performing abscess incision and drainage to the patient. Furthermore, I confirm that my physician has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure of incision and drainage of an abscess.

DISCLOSURE
The informed consent process is an important communication between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
I understand the purpose of fracture care is to identify if a fracture is present and to provide stabilization of the fracture to reduce risk of fracture displacement (movement of the fracture while broken where bones are not lined up), avoid nerve and blood flow compromise due to fracture, to maintain long term normal range of motion of the joint, to provide pain management by immobilization of the fracture as well as provide appropriate referral to a specialist for definitive care.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Injury to the surrounding tissue.
• Fracture displacement (movement of the fracture where the broken bone does not line up).
• Compartment syndrome (when a splint is too tight, if the ACE wrap is not loosened, it may decrease blood supply to the extremity).
• Skin breakdown from the splint resulting in skin irritation and/or bleeding. (If the splint’s plaster rubs on the skin it can cause an abrasion).
• Skin infection from skin breakdown from the splint (above).
• Need for definitive care by a specialist.
• Patient discomfort.
• Allergic reaction to the medications and supplies used to apply the splint.

I understand that fracture care at Pediatric People is an acute temporary fracture care with immobilization by a splint today, ALL patients will require follow up by a specialist for definitive fracture care. Therefore, in addition to splint application today, your child will need to be seen for additional care that may require but is not limited to casting/other forms of immobilization of the injury and/or surgery and physical therapy per specialist recommendations.

I understand that complications may result from fracture care. The most common complications include, but are not limited to: injury to surrounding tissue, fracture displacement despite splinting today, compartment syndrome, skin breakdown, skin infection and bleeding, allergic reaction to medications and supplies used during splinting, and the need for additional specialized care by an Orthopedist and/or Physical therapist that may include surgery, casting and/or other forms of immobilization.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide benefit of provide stabilization of the fracture to reduce risk of fracture displacement (movement of the fracture while broken where bones do not line up), avoid nerve and blood flow compromise due to fracture, to maintain long term range of motion of the joint, to provide pain management by immobilization of the fracture as well as provide appropriate referral to a specialist for definitive care. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure, relapse and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be referred for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that there are risks and complications associated with this procedure and that these risks and complications are rare.

I understand that because of the patient’s known health condition(s), there are additional risks identified above.

I understand that if complications occur, the patient may need to undergo additional medical procedures and/or be taken to a hospital for continued care. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to Pediatric People to perform such procedures at their discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, with my signature, to local anesthesia being administered to the patient, if medically necessary. Furthermore, I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.

DISCLOSURE
The informed consent process should be considered an important conversation between you and the patient’s physician. The end of this form allows you to attest that all questions have been answered to your satisfaction and that you are giving informed consent. You are advised to read this form carefully and use this opportunity as an information seeking session.

If, after you have read and reviewed this form with the patient’s physician, you do not believe that you truly understand the risks, do not sign the form until all your questions have been answered.

PURPOSE
An umbilical granuloma occurs due to inflammation of the umbilical stump resulting in a moist, draining, red lump of tissue on the baby’s navel (belly button). I understand the purpose of umbilical granuloma cautery is to resolve drainage and tenderness from the healing umbilicus and allow for normal skin healing.

IMPORTANT INFORMATION ABOUT THIS PROCEDURE
Most common complications include but are not limited to:

• Injury to the surrounding tissue including skin irritation.
• Patient discomfort during and after procedure.
• Need for repeated cauterization.
• Failure of the procedure.
• Infection and bleeding.

PARENT OR LEGAL GUARDIAN’S CONSENT
I understand that some patients do not respond successfully to umbilical granuloma cauterization with silver nitrate. In some cases, there is the need for additional procedures or repeated cautery.

I understand that there are risks and complications associated with this procedure and that these risks and complications are rare as a result from umbilical granuloma cauterization with silver nitrate. The most common complications include, but are not limited to: injury of the surrounding tissues, irritation of the skin, patient discomfort during and after procedure, infection and bleeding.

I understand that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. In most cases, the treatment should provide the benefit of resolving drainage and tenderness from the healing umbilicus and allow for normal skin healing. Due to individual patient differences, certainty of success cannot be predicted. There is risk of failure and additional treatment despite the best possible care.

I understand that if complications occur, the patient may need to undergo additional medical procedures, and/or be referred to a specialist for additional treatment. I understand that in the course of this procedure it may become necessary to perform additional procedures which are not known to be needed at this time. I request that and hereby provide my informed consent to the physician to perform such procedures at his or her discretion if needed during the procedure.

I understand that my insurance company may not consider the procedure medically necessary, and as a result, refuse to pay the claim charges. If this occurs, I understand that I am required to pay, in full, the insurance company’s physician negotiated and contracted reimbursement discount amount.

I, consent, for the procedure above to be performed with my signature. I confirm that the provider has discussed the above information with me. I’ve had the opportunity to ask questions. All of my questions have been answered to my satisfaction and I do hereby agree and consent for the patient to undergo the procedure.